Counseling to Prevent Tobacco Use

Transcription

1 News Flash Vaccination is the Best Protection Against the Flu. This year, the Centers for Disease Control and Prevention (CDC) is encouraging everyone 6 months of age and older to get vaccinated against the seasonal flu. The risks for complications, hospitalizations and deaths from the flu are higher among individuals aged 65 years and older. Medicare pays for the seasonal flu vaccine and its administration for seniors and others with Medicare with no co-pay or deductible. And remember, vaccination is particularly important for health care workers, who may spread the flu to high risk patients. Don t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, visit on the CMS website. MLN Matters Number: MM7133 Related Change Request (CR) #: 7133 Related CR Release Date: September 30, 2010 Effective Date: August 25, 2010 Related CR Transmittal #: R125NCD and R2058CP Implementation Date: January 3, 2011 Counseling to Prevent Tobacco Use Provider Types Affected Provider Action Needed Physicians and providers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for tobacco cessation counseling services provided to Medicare beneficiaries who are outpatients or are hospitalized are affected. STOP Impact to You This article is based on Change Request (CR) 7133 which announces that the Centers for Medicare & Medicaid Services (CMS) will cover counseling to prevent tobacco use for outpatient and hospitalized beneficiaries. statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement Page 1 of 6

2 CAUTION What You Need to Know Effective for claims with dates of service on and after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries 1) who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease; 2) who are competent and alert at the time that counseling is provided; and 3) whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner. These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations. The ICD-9 diagnosis codes that should be reported for these individuals are (non-dependent tobacco use disorder) or V15.82 (history of tobacco use). Background GO What You Need to Do New G codes and C codes are also created for these services. See the Background and Additional Information Sections of this article for further details regarding these changes and the use of the new G and C codes. Medicare Part B (Section of the National Coverage Determination (NCD) Manual) already covers cessation counseling for individuals who: 1. Use tobacco and have been diagnosed with a recognized tobacco-related disease, or, 2. Use tobacco and exhibit symptoms consistent with a tobacco-related disease. In November 2009, based upon authority to cover additional preventive services for Medicare beneficiaries if certain statutory requirements are met, the CMS initiated a new national coverage analysis. This analysis was to evaluate whether the existing evidence on counseling to prevent tobacco use is sufficient to extend national coverage for cessation counseling to those individuals who use tobacco (but do not have signs or symptoms of tobacco-related disease). One of these statutory requirements is that the service be categorized as a grade A (strongly recommends) or grade B (recommends) rating by the US Preventive Services Task Force (USPSTF). CR 7133 instructs that, effective for claims with dates of service on and after August 25, 2010, CMS will cover counseling to prevent tobacco use for outpatient and hospitalized Medicare beneficiaries: Page 2 of 6

3 1. Who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease); 2. Who are competent and alert at the time that counseling is provided; and, 3. Whose counseling is furnished by a qualified physician or other Medicarerecognized practitioner. These individuals who do not have signs or symptoms of tobacco-related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations. The diagnosis codes that should be reported for these individuals are: ICD-9 code (non-dependent tobacco use disorder), or ICD-9 code V15.82 (history of tobacco use). The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for dates of service on or after January 1, These are in addition to the two CPT codes and that currently are used for tobacco cessation counseling for symptomatic individuals. Medicare will waive the deductible and coinsurance/copayment for counseling and billing with these two new G codes on or after January 1, The new G codes for use on claims with dates of service on or after January 1, 2011 are: G0436: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, Short Descriptor: Tobacco-use counsel 3-10 min; G0437: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, Short Descriptor: Tobacco-use counsel >10 min. Medicare will pay claims not paid under the Outpatient Prospective Payment System (OPPS) with dates of service on or after August 25, 2010, through December 31, 2010, but received prior to January 1, 2011, when billed with diagnosis code (non-dependent tobacco-use disorder) or V15.82 (history of tobacco use) and unlisted HCPCS code for Counseling to Prevent Tobacco Use Services. Code is Medicare contractor-priced. However, two new, temporary C codes have been created for facilities paid under the OPPS when billing for Counseling to Prevent Tobacco Use and Tobacco- Related Disease services during the interim period of August 25, 2010, through December 31, (Facilities paid under the OPPS may not bill the unlisted code.) The two new C codes are: Page 3 of 6

4 C9801: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, Short descriptor: Tobacco-use counsel 3-10 min; C9802: Long Descriptor: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, Short descriptor: Tobacco-use counsel >10 min. CMS will allow two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate OR intensive sessions, with a total benefit covering up to 8 sessions per year per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than 3 minutes up to 10 minutes) or intensive (more than 10 minutes) cessation counseling sessions for each attempt. Note: Section 4104 of the Affordable Care Act provided for a waiver of the Medicare coinsurance and Part B deductible requirements for counseling to prevent tobacco use services, codes G0436 and G0437, effective on or after January 1, No other tobacco cessation codes are eligible for waiver of coinsurance/deductible at this time. Prior to January 1, 2011, this service will be subject to the standard Medicare coinsurance and Part B deductible requirements. The method of payment to institutional providers for outpatient services is as shown in the following table: Type of Facility Method of Payment Rural Health Centers (RHCs)(Type of Bill (TOB) 71X/Federally Qualified Health Centers (FQHCs) (TOB 77X) Hospitals (TOBs 12X and 13X) Indian Health Services (IHS) (TOB 13X) Skilled Nursing Facilities (SNFs) (TOBs 22X and 23X) Home Health Agencies (HHAs) (TOB 34X) All-inclusive rate (AIR) for the encounter OPPS for hospitals subject to OPPS Medicare Physician Fee Schedules (MPFS) for hospitals not subject to OPPS AIR for the encounter MPFS MPFS Page 4 of 6

5 Type of Facility Critical Access Hospitals (CAHs) (TOB 85X), IHS CAHs (TOB 85X) Maryland Hospitals Method of Payment Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Based on specific rate Payment is based according to the Health Services Cost Review Commission (HSCRC) that is 94% of submitted charges subject to any unmet deductible, coinsurance, and non-covered charges policies. Note also the following claims processing information from CR 7133: Claims submitted with the tobacco cessation counseling codes of G0436 and G0437, but which lack a required diagnosis code (305.1 or V15.82) will be denied with Claim Adjustment reason Code (CARC) 167 (This (these) diagnosis (es) is (are) not covered. Note: Refer to the 835 Health Care Policy Identification Segment (loop 2110 Service Payment Information REF), if present.), Remittance Advice Remarks Code (RARC) M64 (Missing/incomplete/invalid other diagnosis), and Group Code PR assigning financial liability to the beneficiary if a claim is received with a signed Advance Beneficiary Notice (ABN). If no ABN is on file, Group Code CO is used to assign financial liability to the provider. Claims are accepted for G0436 and G0437 with revenue code 0942 on TOB 12X, 13X, 22X, 23X, 34X, and 85X. Claims are accepted for G0436 and G0437 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II under the MPFS. Claims are accepted for G0436 and G0437 with revenue code 052X when billed on TOBs 71X or 77X. Claims are accepted for G0436 and G0437 with revenue code 0510 when billed by IHS facilities. Institutional claims billed on TOBs other than 12X, 13X, 22X, 23X, 34X, 71X, 77X, or 85X will be returned to the provider. When claims are denied for exceeding a combined total of eight (8) sessions within a 12-month period, the claims will be denied using CARC 119 (Benefit maximum for this time period or occurrence has been reached.), RARC N362 (The number of days or units of service exceeds our acceptable maximum.), Page 5 of 6

6 and Group code PR if a signed ABN is on file. A Group Code of CO is assigned if no ABN is on file. NOTE: In calculating a 12-month period, 11 months must pass following the month in which the 1st Medicare covered cessation counseling session was performed. Medicare will allow payment for a medically necessary Evaluation and Management (E/M) service on the same date as tobacco cessation counseling, provided it is clinically appropriate. Such E/M service should be reported with modifier 25 to indicate it is separately identifiable from the tobacco use service. Additional Information The official instruction, CR 7133, was issued to your carrier, FI, or A/B MACs via two transmittals. The first transmittal modified the NCD Manual and it may be viewed at on the CMS website. The second transmittal modifies the Medicare Claims Processing Manual and it is available at on that site. If you have questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found at on the CMS website. Page 6 of 6